Doctors hope Karnataka’s right-to-die order sparks conversations on end-of-life care

In a landmark move, Karnataka recently went ahead and implemented a directive simplifying end-of-life decisions for terminally ill patients.

The state follows Kerala to become the second in India to act on a 2023 Supreme Court ruling, which had clearly laid down guidelines on passive euthanasia.

This stemmed from a petition filed by an NGO pointing out that an earlier 2018 SC judgement on the right to die with dignity had led to unwanted delays, due to "cumbersome" procedures laid down to get a verdict on removing life sustaining support from a patient suffering from a terminal illness.

This new directive by the Karnataka health department follows the 2023 judgement and essentially simplifies the process of withdrawing life support, for instance, by tapping into existing medical panels under the Transplantation of Human Organs and Tissues Act (THOTA). In this way, hospitals, which have to take approval of two medical boards, don't have to go hunting for doctors to give a decision.

This directive also helps to make it easier for families and doctors to navigate difficult end-of-life decisions and also ensure that patients have a dignified passing.

Watch | Key judgments of the Supreme Court in the year 2023, a review

The Supreme Court ruling also talks about the Advanced Medical Directive or the Living Will, which allows individuals to document medical preferences in advance if they end up getting bedridden or get on life support.

The directive addresses the challenges faced by families and doctors during critical moments, ensuring decisions are made efficiently and compassionately. Dr Dominic Benjamin, HOD of Geriatric Medicine at Bangalore Baptist Hospital cannot stress enough the importance of being able to die with dignity.

"To die with dignity is an intrinsic right. When someone loses cognitive abilities or is in a vegetative state, decisions must be guided by dignity and compassion,” said Dr Benjamin.

How SC guidelines speeds up process

Firstly, under the 2023 Supreme Court guidelines, the experience of doctors required to form the two medical boards required to certify that life support can be withdrawn from a terminally ill patient, has been reduced to five years from 20 years, said Sai Spandana from Supreme Court Observer, a platform archiving and simplying all Supreme Court judgements in the country.

Both boards must 'preferably' give their decisions within 48 hours, she pointed out.

Also, Dr Simha, who runs Karunashraya, a 73-bed cancer hospitce in Bengaluru, pointed out this Karnataka directive has made it easier for the district health officer to nominate a doctor from an existing panel of doctors that cater to THOTA. They don't have to waste time and keep hunting for doctors to nominate each time, said Dr Simha, who is the medical director of Karunashraya, a 73-bed cancer hospice in Bengaluru.

"This is a wonderful thing that the Karnataka government has done. Now, hospitals can choose any doctor pre-approved by the Transplantation Act to form the secondary medical board and don't have to compulsorily get a government doctor," said Dr Simha, adding that such a move is a first in the country. He hoped that other states will follow suit and implement the guidelines laid down in the 2023 SC 'right to die with dignity' judgement.

The key changes now include reducing the experience requirement for medical board doctors from 20 years to 5 years, allowing the district health officer (DHO) to nominate doctors from an existing medical panel, streamlining approvals so that medical boards give decisions within 48 hours.

Previously, families and hospitals tussled with bureaucratic permissions, adding to their emotional and financial burdens. According to doctors, now the process will be more structured and efficient.

Also read: Living Will | Let's bring dignity in death to the terminally ill

The Advanced Medical Directive or Living Will

The Living Will, which is part of the SC judgement is not a new concept in Karnataka. This document carries the wishes of a person who writes down how they want to be medically treated if they become seriously ill.

The SC judgement said that the Living Will is to be signed by a notary or gazetted officer and witnesses. But, there are still some finer points that has to be ironed out in the case of the Advanced Medical Directive in Karnataka, said Dr Simha.

Encouraging conversations about end-of-life care

Dr Benjamin also pointed out that he hoped that the Karnataka directive will spark off important conversations around end-of-life care. There is a need for families to openly discuss end-of-life care and the importance of a Living Will. Dr Benjamin remarked: “Talking about death is still taboo in India. But patients must communicate their wishes to their children when they are clear-headed. This avoids second-guessing later by the family, who go through a lot of guilt and emotional trauma if they are asked to pull the plug on life support. This can be prevented."

A Living Will, therefore, empowers patients to retain autonomy over their medical treatment, even if they lose the ability to make decisions. As Dr Benjamin said, “Tell me, who wants to die in an ICU? Most people wish to pass in the warmth of their home. It’s essential to discuss these choices early on, so you can have a dignified death.”

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